This blog is based on an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
This blog is written by Penny Rapaport, NIHR Advanced Fellow & Clinical Psychologist, University College London. Penny Rapaport develops and tests interventions to support those affected by dementia and memory problems, especially among marginalised groups.
The issue
The population of people experiencing homelessness is getting older. People who are homeless often have many additional challenges such as physical and mental health problems, drug and alcohol issues and a history of head injury. This means that they are more likely to have memory loss and problems with their thinking and functioning than those who have not experienced homelessness, especially as they age.
Little research has been done in this area; there are gaps in what we know about how best to support people experiencing homelessness and memory problems. Earlier research and practice tells us that it can be hard to support older people with memory problems to move on from ‘temporary’ hostel accommodation, meaning that they stay longer in hostels. Older people with memory problems need more intensive support from staff, have higher social care needs and use more emergency and out of hours services than those without.
In our current study, we set out to learn from older people what it is like to experience homelessness and memory problems together. We also wanted to hear from those providing services and supporting older people experiencing homelessness. Therefore, we interviewed 17 older people experiencing memory problems and homelessness, 15 hostel staff and managers, and 17 health, housing and social care practitioners from hostels and services in England. We asked about their experiences of memory problems and homelessness and what challenges they faced.
The population is not taken seriously
Both staff and those experiencing homelessness told us that they did not feel that they (or their memory difficulties) were taken seriously. Memory problems were put down to drug and alcohol use, even when this was not the case. One hostel worker told us:
“I think it happens quite a lot with the drug users immediately when I go: ‘he has a bad memory’, ‘well he’s a drug user’. I mean, they just write it off as drug use when actually, sometimes it’s not drug use.”
Older people told us they felt overlooked and dismissed:
“Well, you packed your things so you must know’ that is it. It is the total whole sum. ‘Oh, you have got something missing, where is it gone? Oh, you probably lost it in the move or left it in this place or that place.”
Multiple causes are hard to disentangle
Staff felt that it was “difficult to see the wood for the trees” as memory problems often had lots of different potential causes. Usually when people have memory problems, friends, family and other people can fill in the gaps. But because people who experience homelessness may have moved often and lost contact with family, there were often gaps in what they could remember and what staff could piece together about their past and present.
“The timeline of events that these people have gone through … nobody could process that and now they don’t remember themselves”.
Vulnerability and risk of exploitation
Many of the older people described feeling frightened and unsafe in their hostel accommodation; they also spoke about doubting themselves as they were often unsure whether they had lost something (money, for example) or whether someone had taken advantage of them:
“It is a living nightmare, constantly people ask me for money and they borrow money from me and knocking at your door and early hours of the morning for a bit of tobacco, you know… And that’s why I don’t trust anyone in here.”
Staff found it hard keep individuals safe, especially in hostels with a chaotic environment, which is not set up for people with memory problems.
Disconnection and social isolation
Perhaps unsurprisingly, older people tended to be isolated and to keep themselves to themselves; they often lacked any stimulation at all. Many were embarrassed by their difficulties or had trouble interacting socially.
“Yes, you go to have a conversation and the words come but then all of a sudden they dislodge, and then your confidence goes.”
Staff were aware that this isolation and lack of stimulation was not good for those with memory problems but struggled to find ways to address this, since homelessness hostels are not set up to provide care and a more homely environment.
“I think with memory problems that isolation just makes it worse. And, you know, can accelerate its deterioration.”
What can we do?
Our qualitative study included 49 interviews with people who had experience of homelessness and memory problems, and professionals commissioning or working in relevant services. Their detailed answers included suggestions about how frontline workers and service providers can support older people experiencing memory problems.
Participants suggested, for example, that hostel workers:
- spend time getting to know residents
- communicate simply and clearly and do not assume that people understand
- notice patterns in behaviour and how difficulties affect functioning (and share this information within the team)
- use memory aids and visual prompts.
- support people to develop routine and structure in their day.
They suggested that those commissioning and delivering services:
- arrange for services assessing memory or functioning, for example, to visit hostels to make access easier
- recognise and take seriously the expertise of front-line staff
- develop bespoke accommodation for those experiencing homelessness and memory problems
- have more flexible admission criteria for services; and, for example, do not exclude people from memory services if they are currently drinking alcohol.
We have used our findings to co-design a training and support intervention for staff working in homelessness hostels who support older people with memory problems.
The intervention aims to help staff:
- understand memory problems
- communicate with and about residents with memory problems
- use strategies for reducing risk
- support residents to access services and find settled accommodation.
The intervention combines face to face training with trying out changes in practice; it includes follow up support sessions which allow staff to reflect on and share what is working well. We are now testing the intervention in hostels as part of the same NIHR funded HOME study and look forward to sharing our results.
You may be interested to read
This blog is based on: Rapaport P, and others. A qualitative exploration of older people’s lived experiences of homelessness and memory problems – stakeholder perspectives. BMC Geriatrics. 2023; 23(556).
Website for this research project.
Further research on service provision for older homeless people with memory problems: Manthorpe J, and others. Service provision for older homeless people with memory problems: a mixed-methods study. Health Services and Delivery Research. 2019; 7(9).
Funding: The study was funded by the NIHR Advanced Fellowship Programme.
Conflicts of Interest: The study authors declare no conflicts of interest.
Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
